1. Transition to Extrauterine Life

3. Pulmonary System Transition
Function of respiration switches from the placenta to the lungs
Factors responsible for onset of breathing
Hypercapnia
Hypoxia
Acidosis
Environment (cold, light, noise)
Fluid in the lungs must be cleared
Pulmonary arterioles dilate, PVR level falls

4. Respiratory Adapations
Mechanical changes
Chemical changes
Thermal changes
Sensory changes

5. Fetal and Neonatal Circulation
Table 28–1 Fetal and neonatal circulation.

6. Normal Term Newborn Cord Blood
Table 28–2 Normal term newborn cord blood values.

7. Neutral Thermal Environmental Temperatures
Table 28–3 Neutral thermal environmental temperatures.

8. Jaundice
Table 28–4 Jaundice.

9. Physiologic Adaptations to Extrauterine Life
Table 28–5 Physiologic adaptations to extrauterine life.

10. Newborn Urinalysis Values
Table 28–6 Newborn urinalysis values.

11. Cardiac System Transition
Pressure in right side of the heart falls and pulmonary venous return to left atrium increases
Foramen ovale closes due to these changes
Ductus arteriosis constricts and closes functionally by 96 hours
Ductus venosis constricts and closes functionally by two to three days

12. Cardiovascular Adaptations
Decreased pulmonary vascular resistance and increased blood flow
Increased systemic pressure and closure of ductus venosus
Increased left atrium and decreased right atrium pressure
Closure of foramen ovale
Reversal of blood flow through ductus arteriosus and increased PO2
Closure of ductus arteriosus

13. Figure 28–4 Transitional circulation: conversion from fetal to neonatal circulation.

14. Figure 28–6 Fetal-neonatal circulation
Figure 28–6 Fetal-neonatal circulation. A, Pattern of blood flow and oxygenation in fetal circulation. B, Pattern of blood flow and oxygenation in transitional circulation of the newborn. C, Pattern of blood flow and oxygenation in neonatal circulation.

15. Figure 28–6 (continued) Fetal-neonatal circulation
Figure 28–6 (continued) Fetal-neonatal circulation. A, Pattern of blood flow and oxygenation in fetal circulation. B, Pattern of blood flow and oxygenation in transitional circulation of the newborn. C, Pattern of blood flow and oxygenation in neonatal circulation.

16. Figure 28–6 (continued) Fetal-neonatal circulation
Figure 28–6 (continued) Fetal-neonatal circulation. A, Pattern of blood flow and oxygenation in fetal circulation. B, Pattern of blood flow and oxygenation in transitional circulation of the newborn. C, Pattern of blood flow and oxygenation in neonatal circulation.

17. Fetal Laboratory Value Changes
Decreased erythropoietin production
Rise of hemoglobin concentration
Physiologic anemia of infancy
Leukocytosis
Decreased percentage of neutrophils

18. Thermoregulation
Body heat lost easily due to large body surface area in relation to weight
Limited neonatal fat stores
Limited capacity for heat production
Brown-fat metabolism is primary heat source

19. Thermoregulation (continued)
Normal axillary temperature is 97°F–99.5°F
Hypothermia is <97.0
Goal is to keep infant in a neutral thermal environment

20. Thermogenesis in the Newborn
Large body surface area compared to mass
Types of heat loss
Convection
Radiation
Evaporation
Conduction

21. Figure 28–9 Methods of heat loss. A, Convection. B, Radiation
Figure 28–9 Methods of heat loss. A, Convection. B, Radiation. C, Evaporation. D, Conduction.

22. Figure 28–9 (continued) Methods of heat loss. A, Convection
Figure 28–9 (continued) Methods of heat loss. A, Convection. B, Radiation. C, Evaporation. D, Conduction.

23. Figure 28–9 (continued) Methods of heat loss. A, Convection
Figure 28–9 (continued) Methods of heat loss. A, Convection. B, Radiation. C, Evaporation. D, Conduction.

24. Figure 28–9 (continued) Methods of heat loss. A, Convection
Figure 28–9 (continued) Methods of heat loss. A, Convection. B, Radiation. C, Evaporation. D, Conduction.

25. Types of Bilirubin Unconjugated bilirubin Conjugated bilirubin
Total bilirubin

26. Conjugation and Excretion of Bilirubin
Bilirubin is transported in blood via albumin
Bilirubin is transferred into the hepatocytes
Attachment of unconjugated bilirubin to glucuronic acid
Excreted into bile ducts, then into the common duct and duodenum
Bacteria transform it into urobilinogen and stercobilinogen
Bilirubin is excreted in urine and stool

27. Physiologic Jaundice Accelerated destruction of fetal RBCs
Increased amounts of bilirubin delivered to liver
Inadequate hepatic circulation
Impaired conjugation of bilirubin
Defective uptake of bilirubin from the plasma
Defective conjugation of the bilirubin

28. Physiologic Jaundice (continued)
Increased bilirubin reabsorption
Defect in bilirubin excretion
Increased reabsorption of bilirubin from the intestine

29. Liver Adaptations Iron content stored in liver
Low carbohydrate reserves
Main source of energy is glucose
Liver begins to conjugate bilirubin
Lack of intestinal flora results in low levels of vitamin K

30. GI Adaptations Sufficient enzymes except for amylase
Digests and absorbs fats less efficiently
Salivary glands are immature
Stomach has capacity of mL
Cardiac sphincter is immature

31. Fluid and Electrolyte Balance
Less able to concentrate urine
Limited tubular reabsorption of water
Limited excretion of solutes
Limited dilutional capabilities

32. Immunologic Responses in the Newborn
IgG – passive acquired immunity via placenta
IgM – usually not passively transferred
Elevated levels may indicate fetal antigenic activity in utero
IgA – passive acquired immunity via colostrum

33. Periods of Reactivity First period of reactivity Sleep phase
Second period of reactivity

34. Behavioral and Sensory Capabilities
Habituation
Orientation
Auditory
Olfactory
Tasting and Sucking
Tactile

35. Nursing Interventions to Prevent Hypothermia
Dry infant, remove wet blankets
Apply a hat and warm blankets
Avoid placing infant on cold surfaces
Avoid placing infants in drafts

36. Nursing Interventions to Prevent Hypothermia (continued)
Use heat source when bathing infants
Place under radiant warmer if temperature is unstable

37. Metabolic Transition
Infant’s source of nutrition from the placenta terminates at birth
Blood sugar reaches its lowest point one to three hours after birth
Glucose stabilizes by four to six hours after birth
Range of 45–80 mg/dl is normal

38. Gastrointestinal System
At birth abdomen is flat and bowel sounds are absent
Abdomen becomes rounded and soft with onset of respirations
Bowel sounds usually audible within 15 minutes of birth

39. First Period of Reactivity
First minutes after birth
Characteristics
Alert, active, sucking activity, tachycardia, tachypnea, transient rales and nasal flaring
Implications for the family
Infant alert and responsive
Allow quiet time for family to be together
Introduce breastfeeding

40. Period of Decreased Activity
Follows first period of reactivity
Characteristics
Less alert and active, sleep may occur, vital signs normalize

41. Period of Decreased Activity (continued)
Implications for the family
Family may stay together or infant may be taken to nursery for assessment
Opportunity for parents to have quiet time
Mother may use this time to rest

42. Second Period of Reactivity
Infant awakens and shows increased responsiveness to the environment
Characteristics
Peristalsis increases and meconium may be passed, gagging, spitting up
Implications for the family
Allow time together if mother is rested
Parents may begin to have questions or need assistance with newborn care

43. Asphyxia Arises from inadequate or absent respiration
Impairment of oxygen/carbon dioxide exchange
Hypoxemia, hypercarbia, respiratory acidosis
Assessment findings
Poor tone, gasping or absent respirations, bradycardia, cyanosis, low Apgar score

44. Asphyxia (continued) Management Tactile stimulation
Positive pressure ventilation with 100% oxygen

45. Meconium Staining Caused by distress, usually asphyxia
Risk is that fetus/infant may aspirate
Obstruction, chemical pneumonia may result
Assessment findings
Respiratory distress, hypoxemia
Prevention
Suctioning nose/mouth before delivery of the chest
Appropriate suctioning post delivery

46. Transient Tachypnea of the Newborn
Characteristics
Grunting, retracting, tachypnea
Risk factors
Cesarean delivery, precipitous delivery
Management
Oxygen therapy
IV fluids
Short-term ventilation
Antibiotics if sepsis is suspected

47. Hypoglycemia Plasma glucose level below 40 mg/dl Assessment findings
Jitteriness, tremors, apnea, cyanosis, lethargy
Risk factors
SGA, preterm, perinatal stress, IDM, sepsis

48. Hypoglycemia (continued)
Management
Early feeding of infants at risk
Keep infant warm
Glucose by nipple, gavage, or IV
Recheck blood glucose 30 minutes after feeding

49. Transition of the Premature Infant
Pulmonary system
Inadequate alveolar development, lack of surfactant
May require ventilatory support
Administration of surfactant
Cardiac system
Persistent ductus arteriosis (PDA)
Indomethacin given to facilitate closure

50. Resuscitation and Stabilization in the Delivery Room
Dry and provide warmth, tactile stimulation
Clear airway
Resuscitation for compromised infants
Place under radiant warmer, stimulate
Position to ensure a patent airway
Suction using appropriate technique
Evaluate respirations, heart rate, color

51. Resuscitation and Stabilization in the Delivery Room (continued)
Resuscitation for compromised infants (continued)
Administer oxygen if indicated
Bag-mask ventilation if apneic
Medications may be indicated if infant does not respond

52. Nursing Care of the Normal Newborn

53. Chapter 30
The Normal Newborn: Needs
and Care

54. Assessment Data: Condition of the Infant
Apgar scores at 1 and 5 minutes
Resuscitative measures
Physical examination
Vital signs
Voidings
Passing of meconium

55. Signs of Newborn Transition
Table 30–1 Signs of newborn transition.

56. Neonatal Distress
Table 30–2 Signs of neonatal distress.

57. Newborn Care
Table 30–3 What parents need to know about newborn care.

58. Newborn Care
Table 30–3 (continued) What parents need to know about newborn care.

59. When to Call for Help
Table 30–4 When parents should call their healthcare provider.

60. Assessment Data: Infant Complications
Excessive mucus
Delayed spontaneous respirations or responsiveness
Abnormal number of cord vessels
Obvious physical abnormalities

61. Assessment Data: Labor and Birth
Duration and course
Status of mother and fetus
Analgesia or anesthesia

62. Assessment Data: Labor and Birth Complications
Prolonged rupture of membranes
Meconium-stained amniotic fluid
Nuchal cord
Precipitous birth
Use of forceps or vacuum extraction assisted device
Fetal distress

63. Assessment Data: Maternal Complications
Preeclampsia
Spotting
Illness
Recent infections
Rubella status
Serology results

64. Assessment Data: Maternal Complications (continued)
Hepatitis B screen results
Exposure to group B streptococci
History of maternal substance
Human immunodeficiency virus (HIV) test result

65. Assessment Data: Family
Parents’ interactions with their newborn
Their desires regarding infant care
Information about other children in the home
Available support systems
Patterns of interaction within each family unit

66. Physiologic Alterations
Respiratory distress
Pallor
Hypothermia
Alterations in feeding and elimination

67. Nursing Care: Assessment
Airway clearance
Vital signs
Body temperature
Neurologic status
Ability to feed
Evidence of complications

68. Figure 30–2 Temperature monitoring for the newborn
Figure 30–2 Temperature monitoring for the newborn. A skin thermal sensor is placed on the newborn’s abdomen, upper thigh, or arm and secured with porous tape or a foil-covered foam pad. SOURCE: Photographer, Elena Dorfman

69. Nursing Care: Assessment (continued)
Review of prenatal and birth information
Gestational age
Newborn’s adaptation to extrauterine life
Weight and measurement
Vital signs every 30 minutes
Assessment of Hct or blood glucose if warranted

70. Figure 30–1 Weighing a newborn
Figure 30–1 Weighing a newborn. The scale is balanced before each weighing, with the protective pad in place.

71. Admission Procedures Newborn bath Vitamin K Eye prophylaxis
Observation for distress
Initiate feeding
Facilitate parental-infant attachment

72. Figure 30–3 Procedure for vitamin K injection
Figure 30–3 Procedure for vitamin K injection. Cleanse area thoroughly with alcohol swab, and allow skin to dry. Bunch the tissue of the upper thigh (vastus lateralis muscle) and quickly insert a 25-gauge 5/8-inch needle at a 90-degree angle to the thigh. Aspirate, then slowly inject the solution to distribute the medication evenly and minimize the baby’s discomfort. Remove the needle and massage the site with an alcohol swab. SOURCE: Photographer, Elena Dorfman

73. Figure 30–5 Ophthalmic ointment
Figure 30–5 Ophthalmic ointment. Retract lower eyelid outward to instill a 1/4-inch strand of ointment from a single-dose ampule along the lower conjunctival surface.

74. Eye prophylaxis
Vitamin K administration
First bath

75. Daily Assessments Vital signs Weight Overall color Intake and output
Umbilical cord
Circumcision

76. Daily Assessments (continued)
Newborn feeding
Attachment

77. Daily Newborn Care Assist with feedings Thermoregulation Skin care
Cord care
Prevention of infection
Security

78. Figure 30–6 The umbilical cord base is carefully cleaned.

79. Common Concerns How to pick up a newborn
Holding and feeding the infant
Changing the diaper
Interpreting newborn cues
Bathing the newborn

80. Figure 30–11 A father demonstrates competence and confidence in diapering his newborn daughter.

81. Common Concerns (continued)
Cord and circumcision care
Normal voiding and stooling pattern

82. Parent Education Periods of reactivity and expected newborn responses
Normal physical characteristics of the newborn
The bonding process
The infant’s capabilities for interaction
The role of touch in facilitating parent-infant interaction
Comforting techniques

83. Parent Education (continued)
Progression of infant behaviors
Information about available educational materials and support

84. Family Education Newborn care videos Newborn care classes
Individual instruction
Observation of parent-infant interaction
Role modeling

85. Discharge Education Safety measures Voiding and stool characteristics
Circumcision care
Cord care
Waking and quieting the newborn
Car safety

86. Figure 30–9 Following circumcision, petroleum ointment may be applied to the site for the next few diaper changes.

87. Figure 30–13 Steps in wrapping a baby.v
Figure 30–13 Steps in wrapping a baby.

88. Figure 30–14 Infant car restraint for use from birth to about 12 months of age.

89. Discharge Education (continued)
Immunizations
Signs of illness

90. Signs of Illness Temperature above 38oC or below 36.6oC axillary
Continual rise in temperature
Forceful or frequent vomiting
Refusal of two feedings in a row
Difficulty in awakening baby
Cyanosis with or without a feeding

91. Assessment After Transition
Temperature
Normal axillary temperature 97°F–99.5°F
Cardiovascular system
Normal heart rate 120–150 bpm
Observe color, pulse, murmurs

92. Assessment After Transition (continued)
Respiratory system
Normal rate is 30–60/minute
Nose-breather
Observe for flaring, grunting, retracting
Auscultate for rales

93. General Nursing Care Eye prophylaxis
Prevents gonorrhea and chlamydia
Erythromycin or tetracycline ointment
Vitamin K prophylaxis (0.5–1.0 mg)
IM into lateral thigh
Prevents bleeding due to Vitamin K deficiency
First bath
Institute measures to prevent hypothermia

94. General Assessment Position Color Body size Reactivity Identification
Flexion of upper and lower extremities
Symmetrical movement
Color
Acrocyanosis
Jaundice
Body size
Reactivity
Identification

95. Physical Examination Weight Length Head circumference Vital signs
45–54 cm
Head circumference
33–38 cm
Vital signs

96. Gestational Age Assessment
Neuromuscular maturity
Posture
Square window
Arm recoil
Popliteal angle
Scarf sign
Heel-to-ear
Physical maturity
Skin
Lanugo
Plantar surface
Breasts
Eye and ear
Genitalia

97. Skin Assessment Normal findings: color pink Common variations
Milia
Erythema toxicum
Mongolian spots
Birthmarks
Common problems
Petechiae
Blisters, lesions
Plethara
Abnormal hair distribution
Mongolian spot
Birthmark

98. Head, Eyes, Nose, and Throat Assessment
Normal findings
Symmetry in appearance, normal placement
Anterior fontanel open
Common variations
Molding
Caput succedaneum
Cephalhematoma
Teeth

99. Head, Eyes, Nose, and Throat Assessment (continued)
Cephalhematoma
Caput succedaneum

100. Head, Eyes, Nose, and Throat Assessment (continued)
Common problems
Low-set ears
Discolored sclera (yellow, bluish)
Cleft lip, palate
Absent red reflex
Microcephaly, hydrocephaly
Craniostenosis
Features characteristic of FAS

101. Respiratory System Assessment
Normal findings
Symmetrical expansion
Common variations
Accessory nipples
Gynecomastia
Common problems
Retractions
Tachypnea
Rales
Clearing the infant’s mouth
with a bulb syringe

102. Cardiovascular Assessment
Normal findings
Color pink
Normal rate and rhythm
Common variations
Murmurs
Acrocyanosis

103. Cardiovascular Assessment (continued)
Common problems
Persistent murmurs
Cyanosis
Tachycardia, bradycardia

104. Abdominal Assessment Normal findings Common variations
Round, full, symmetrical, plus bowel sounds
Two arteries, one vein in cord
Common variations
Hernia

105. Abdominal Assessment (continued)
Common problems
Two-vessel cord
Distension, absent bowel sounds
Discharge/leakage from the cord
Abdominal mass

106. Genital and Anal Assessment
Normal findings
Patent anus
Testes descended
Stool and urine by 24 hours after birth
Common variations
Hydrocele
Hymenal tag and vaginal discharge

107. Genital and Anal Assessment (continued)
Common problems
Undescended testes
Epispadius, hypospadius
Imperforate anus
epispadius: urinary meatus on top of penis
hyospadius: urinary meatus on underside of penis.

108. Circumcision Risks Benefits Nursing care after circumcision
Bleeding, infection, adhesions, pain
Benefits
Decreased incidence of UTIs
Prevention against penile cancer
Nursing care after circumcision
Observe for bleeding
Observe for voiding difficulties

109. Musculoskeletal Assessment
Normal findings
Normal tone, flexion, symmetrical movement
Common variations
Hip click
Club foot

110. Musculoskeletal Assessment (continued)
Common problems
Fracture (clavicle most common)
Hip dysplasia
Syndactyly/polydactyly
Asymmetrical movement
Simian crease
syndactyly: fusion of 2 or more fingers or toes.
Polydactyly: more than 5 fingers or toes.

111. Neurologic System Normal findings Common problems
Normal reflexes (suck, rooting, grasp, Moro, Gallant, gag, Babinski’s)
Brachial plexus injury (Erb’s palsy)
Spina bifida
Anencephaly
Absent or abnormal reflexes
Seizure activity

112. Periodic Shift Assessment
Vital signs
Weight
Feeding and elimination
Hydration status
Respiratory and cardiac function
Hip movements

113. Factors Placing the Infant at Risk
Physical
Birth injuries, congenital conditions, temperature control
Psychological
Interferences in interaction between parents, newborn
Family
Environment
Illness and infection

114. Nutritional Comparison: Breast Milk
90% water
Same weight gain or greater during first 3-4 months
Fat is variable
Primary carbohydrate is lactose, trace amounts of other carbohydrates

115. Milk Comparisons
Table 31–1 Comparison of selected nutrients in milk.

116. Milk Comparisons
Table 31–1 (continued) Comparison of selected nutrients in milk.

117. Breastfeeding and Formula-feeding
Table 31–2 Comparison of breastfeeding and formula-feeding.

118. Breastfeeding and Formula-feeding
Table 31–2 (continued) Comparison of breastfeeding and formula-feeding.

119. Successful Breastfeeding Evaluation
Table 31–3 Successful breastfeeding evaluation.

120. Pumping Instructions
Table 31–4 Pumping instructions.

121. Types of Pumps
Table 31–5 Types of breast pumps and indications for use.

122. Storage Guidelines
Table 31–6 Storage guidelines for breast milk and formula.

123. Water Sources
Table 31–7 Water sources.

124. Baby-friendly Requirements
Table 31–8 Baby-friendly requirements.

125. Nutritional Comparison: Formula
90% water
Greater weight gain after 3-4 months
Lactose is only carbohydrate

126. Components of Breast Milk
Whey/Casein ratio changes according to infant needs
Whey components include alpha-lactalbumin, serum albumin, lactoferrin, immunoglobulins, and lysozyme
Low in vitamin D, adequate vitamin C & B complex
Mineral content similar
Iron absorption: 50-60%

127. Components of Formula Whey/Casein ratio is 60:40
Whey components are beta-lactoglobulin and alpha-lactalbumin
Adequate amounts of vitamins
Mineral content similar

128. Advantages of Breastfeeding
Species specific
Cholesterol in breast milk plays a role in myelination and neurologic development
More efficient metabolism of cholesterol
Composition varies according to gestational age
Iron is more readily absorbed

129. Infant Benefits Reduced risk of Type I or type II diabetes mellitus
Lymphoma, leukemia, & Hodgkin’s disease
Obesity
Hypercholesterolemia
Asthma

130. Infant Benefits: Immunologic
Protection from
Respiratory tract and gastrointestinal tract infections
Necrotizing enterocolitis
Urinary tract infections
Otitis media
Bacterial meningitis

131. Infant Benefits: Immunologic (continued)
Protection from
Bacteremia
Allergies

132. Maternal Physical Benefits
Decreased postpartum bleeding
More rapid uterine involution
Burns additional calories
Decreased risk of developing
Breast and ovarian cancer
Postmenopausal osteoporosis

133. Maternal Psychosocial Benefits
Improved maternal-infant attachment
Skin-to-skin contact
Tactile communication
Learn behavioral cues and needs
Prolactin increases feelings of relaxation and euphoria
Oxytocin heightens responsiveness and receptivity toward infant

134. Disadvantages to Breastfeeding
Pain due to nipple tenderness
Leaking milk when breasts are full
Embarrassment about breastfeeding
Feeling tied down to the demands of breastfeeding
Unequal feeding responsibilities/fathers left out
Perceptions about diet restrictions

135. Disadvantages to Breastfeeding (continued)
Limited birth control options
Vaginal dryness
Concerns about the safety of medications and breastfeeding

136. Feeding Interventions: Birthing Room
Assess for signs of readiness to feed
Place newborn on mother’s chest
Breastfeeding may begin in birthing room
Assess infant physiologic status during feeding

137. Feeding Interventions
Monitor progress
Education
Anticipatory guidance
Evaluate the need for follow-up after discharge

138. Infant Feeding Education
“On Demand” feeding pattern
Infant feeding cues
Normal feeding/sleeping patterns
Satiety behaviors
Growth patterns

139. Breastfeeding Education
Positioning
Latching
Breast milk pumping and storage
Supplementation

140. Formula Feeding Education
Intake and output expectations
Preparation and storage of formula
Feeding technique
Equipment
Safety precautions

141. Growth Rates
Both breastfed and formula-fed infants experience growth spurts requiring increased feedings
Breastfeeding mother should nurse more frequently
Formula feeding mother should slightly increase amount of feeding

142. Influence of Culture on Infant Feeding
Perception of breasts as sexual organ
Perceptions of colostrum
Language